Part 38

A soldier of the 40th Regiment slipped from the ladder on which he was attempting to scale the wall near the great breach of Badajos, and fell on his cartridge-box, which hurt his left side so much as to render him unable to move for some time. On the 8th of April he was much worse. The part injured was painful to the touch; the difficulty of breathing considerable; cough hard, with little expectoration; pulse 90, skin hot, appetite gone, tongue white. V. S. ad ℥xvj, and aperients. 9th. Better; pain less; expectoration more in quantity, and viscid. V. S. ad ℥xii; antimonials. 10th. Pain still felt on coughing; expectoration reddish; difficulty of breathing greater. Pil. cal. et antim. c. opio; V. S. ad ℥xvj. He gradually recovered (his mouth having become slightly sore) from what was manifestly an attack of pneumonia. A gentleman, in 1835, fell from his shooting-pony on his powder-horn, which bruised his right side from the seventh to the last rib, and, as he said, knocked the breath out of his body, and hurt him so much as to render him incapable of walking from one room to another from pain in the side, back, and thigh. No bones were broken. The pain, on the second day, was augmented on breathing and on attempting to cough. The third day he was purged, and blooded to sixteen ounces, which gave some relief; but as the symptoms increased on the fourth day, he was more carefully examined. His right side could not bear pressure. The respiratory murmur was distinct, but accompanied by a crepitating rhonchus under the part injured. Cough troublesome; expectoration mucous, viscid, and of a reddish tinge. Antim. p. tart. and sulphas magnesiæ, every four hours. V. S. ad ℥xiv. On the fifth day, the symptoms being little altered, he was cupped on the part affected to fourteen ounces. On the sixth, the pain was only felt on coughing, or on drawing a very full breath; expectoration redder and thicker; pulse quicker. The rhonchus was quite as distinct. V. S. ad ℥xij, and the medicines to be continued. After this he quickly recovered and the natural respiration became distinct.

Lieutenant Cooke Tylden Patterson, of the Light Division, was struck on the left breast by a musket-ball, on the morning of the 15th of July, 1813, in front of the village of Vera, in the Pyrenees. He fell on his back breathless, as if he were killed. While waiting the order to advance, he had been reading Gil Blas in Spanish, and on receiving it, had hastily put the book in the breast pocket of his coat. The ball had struck this, but, unable to penetrate it, had fallen on the ground at his feet, completely flattened on one side, and marked with the impression of the braid of his coat. A piece of the cover of the book, about the size of a half-crown, was driven in, and the leaves throughout were indented by the ball. It was some days before the effects of the blow entirely subsided.

A soldier of the 97th Regiment was struck at the unsuccessful assault of Fort Christoval, opposite Badajos, by a musket-ball, which went through his brass breast-plate and coat, drove his shirt through the skin, and against the sternum, which it was not able to penetrate. He fell, and was supposed to be killed, but he soon recovered and ran to the rear. The ball was found flattened between his shirt and coat. The part of the chest was very black next day, the spot struck by the ball being much bruised. It was necessary to bleed him largely. When the integuments are painful, although merely bruised, the diluted tincture of arnica is a useful application, and Scheele’s hydrocyanic acid, six drops to an ounce of water, is said to be efficacious.

Major Lightfoot was struck by a musket-ball on the left breast; it went through his clothes, the integuments and the outer part of the great pectoral muscle, and slanted inward for three inches toward the sternum, to which distance its track could be followed. It was evident that the ball had neither lodged nor penetrated, for no serious symptoms ensued. In all probability it had been ejected the way it went in by the elasticity of the cartilages of the ribs near the sternum.

297. In order to understand, or to become in any way acquainted with the changes from the natural structure which are going on under derangement in the chest, even from simple injuries, it is always necessary to have recourse to auscultation, and sometimes, although more rarely, to percussion, if the external parts are not too tender. Under all circumstances both sides of the chest should be examined by the stethoscope. As the ordinary breathing of an individual is rarely sufficiently strong to enable the auscultator to hear it with distinctness, the patient should be desired to inspire fully and more quickly than usual, without much effort, and without noise from the mouth or nose, or retaining his breath. The inspiration and the expiration are both to be carefully observed.

When the ear is firmly and equably applied to the chest of a healthy young person, a very distinct and long-continued sound is heard at the moment of inspiration, and another at that of expiration. This is called the _vesicular_ or _respiratory murmur_, and is dependent on the air fully permeating and distending the air-vesicles of the lungs. It has been poetically compared to the sound of a gentle gale rustling in a thick summer foliage--to the whisper of a retiring wave on a sandy beach in a calm day. It is soft, scarcely sonorous, equable, and during inspiration continuous. In childhood it is louder than in adult persons, arising probably from the greater activity of the lungs in young than in elderly people. This is called, and especially when perceptible in adults, _puerile respiration_, as opposed to their ordinary, or what in old persons may be called _senile_. It is more marked during inspiration.

When the stethoscope is applied in the situation of the great bronchial passages, as over the first bone of the sternum, under the clavicle, in the center of or between the shoulder-blades, a different sound is usually but not always distinguishable, when the patient breathes fully, arising from the passage of the air through these bronchial tubes. It is compared to the noise made on blowing through a reed or quill, and is called _bronchial or tubular respiration_. When heard in other parts of the chest, it is a morbid sound. If the stethoscope be applied over the trachea, the sound is louder, rougher, and more intense, and is called _tracheal_ respiration. On listening over the trachea during speaking, the voice sounds as if it were passing into the ear, and the words are distinct--_tracheophony_. This, if heard in any other part of the chest, is a sign of disease, for in the natural state the voice is heard only to resound through the chest, but the words are not heard if the other ear be stopped. When heard, the sound has been called _pectoriloquy_, and is supposed to imply the existence of a cavity at that part; but the word is unnecessary, or, if used, it means that the cavern or hollow communicating directly with the trachea gives forth a similar or nearly similar sound, a _natural_ sound in an _unnatural_ position. The essential difference between _bronchophony_ and _tracheophony_ in the investigation of disease is, that in the latter the voice apparently speaks through the stethoscope into the ear of the auscultator, while in the former it is heard with scarcely less distinctness, but at the distal end of the instrument. Over the larynx it is louder, hoarser, and rougher.

The length of the sound in inspiration, as compared with that of expiration, has been said to be as five to two. One is louder and longer than the other, a difference requiring attention from the circumstance that morbid sounds of great import are heard in inspiration, which do not prevail during expiration. When any other difference is perceptible between them, so that they more nearly resemble each other in duration or in intensity, or when expiration is prolonged, some structural alteration may be suspected in old persons, some disease in young ones. When little or no respiratory murmur can be heard after symptoms of inflammation have existed for some time, the case is very serious, implying that effusion into the cavity, or condensation of the lung, has taken place to a considerable extent.

298. The number of inspirations in a minute in the adult and elderly persons varies from eighteen to twenty-two in a state of health: from twenty-two to twenty-six in children. The stroke of the pulse is generally as four to one. If the inspirations are eighteen, the pulse will in general be seventy-two. Both may be slower, although they are often quicker under disease. When the breathing is slower, it commonly indicates some affection of the nervous system; when very rapid, some important lesion within the chest.

The theory of percussion is founded upon three elementary sounds, which are produced when a solid, a liquid, or a gaseous body is struck; all others are varieties of these. The sensation of resistance which is experienced at the same time bears an exact relation to the density of these bodies--hence the resistance when a solid substance is struck is greater than when a gaseous one is under percussion. The liver, the thorax in a case of pleuritic effusion, and the distended stomach after a long fast, afford good examples of these elementary sounds. To employ percussion successfully, it is necessary that the strokes be uniform in force and quickness, and that the finger or pleximeter be so applied to the surface that no space exists between them, otherwise such a sound will be elicited as may give rise to an incorrect diagnosis.

It having been stated that a sound lung never fills the bag of the pleura, particularly toward the diaphragm, at least during ordinary respiration, I requested Mr. Quekett, the Resident Conservator of the College of Surgeons, to ascertain this by experiments on some sheep at the moment of their being killed; and it appeared from them that the base of the lung is always in contact with the surface of the diaphragm.

299. In ordinary expiration the chest diminishes in size. The ribs which have been raised recede, by the elasticity of their cartilages, and by the return of the ligaments, to their state of rest; the elevated muscles become relaxed, while others belonging to the lower part of the trunk and abdomen contract. The diaphragm is relaxed, and pushed upward by the viscera of the abdomen, pressed upon by the muscles of its wall, if it should not be drawn upward by the attraction of the lung, which when distended endeavors by its elasticity to return upon itself, and to occupy less space than the capacity of the chest will afford. The lung, invested by an elastic, special, and transparent membrane, and covered by the pleura pulmonalis, is composed of an immense number of air vesicles, the largest being equal in size to the fourth part of a millet-seed. These air vesicles, crowded together, each communicating with a fine bronchial tubule, are separated from each other into groups by a condensed cellular tissue, thicker where it surrounds these lobules, which alternately form, when aggregated together, a lobe, whence it is called interlobular tissue. An artery and vein form a very minute net-work around each vesicle. These vesicles may become filled with water; when dilated by air, they constitute what is called emphysema of the lung. The lung in man is constantly applied to the internal surface of the chest, the pleura or serous membrane covering the lung being closely applied to the pleura lining the wall, and one surface glides upon the other, moistened by a secretion in just sufficient quantity to effect this object. If the lower intercostal muscles of a young animal be removed to a sufficient extent, the lung and the diaphragm may be seen applied to the inside of the pleura lining the rib, and _ascending_ and _descending_ in concert, the lungs moving vertically, not horizontally. The diaphragm ascending, covered by its pleura, is in a similar manner applied to the lower part of the wall of the chest, which had been filled by the lung during inspiration. After death the lung remains closely applied to the pleura, recedes on an opening being made into that membrane, and may collapse, provided no adhesions exist to prevent it.

300. When inflammation of the pleura takes place, the gliding motion is not effected silently, but with a peculiar noise, called by the French _frottement_. When the lung is inflamed, the respiratory murmur is changed in that part, or is overcome by a peculiar sound, which can be distinctly investigated by the ear--_rhonchus crepitans_. Hence the great value of auscultation.

In the following observations it is not intended to give a history of, or even the whole of the symptoms and consequences of inflammation of the pleura and the lungs; but only to draw attention to such of the principal facts as it may be necessary to consider when these inflammations and their consequences are caused by external injuries.

Acute idiopathic inflammation of the pleura usually commences by rigors, preceded perhaps by some signs of general uneasiness, which soon become those of great febrile excitement. Pain is early felt in the side in the course of the sixth, seventh, and eighth ribs, or at the point corresponding generally to the seat of the inflammation. It is usually sharp and darting, is called a stitch, occupies rather a small space, (the _point de côté_ of the French,) and is always increased by drawing a full breath or by coughing. The breathing is short, from the disinclination to fill the chest, by which the pain would be increased; it is hurried, and sometimes takes place as if by jerks, from the necessity for its repetition, in consequence of the smallness of the quantity of air admitted at each attempt. When the attack is very severe the patient tries to breathe with the healthy side only, the lower ribs of the affected side being moved but slightly, and with evident caution. If the inflammation have been caused by extreme violence, pain will also be felt, particularly at the part injured.

When inflammation has affected the pleura covering the diaphragm, especially when caused by external violence, the pain will be felt lower down, so as to lead to the suspicion that it is also abdominal. When jaundice supervenes, it occurs from the extension of disease through the substance of the diaphragm, as is occasionally seen in wounds implicating the chest, the diaphragm, and the liver.

A cough is not a constant accompaniment of the first stage of disease; when present, it is usually dry, slight, infrequent, and does not attract attention, unless accompanied by a thin, frothy mucous expectoration, indicating the presence of bronchitis; of pneumonia, if reddish. The patient usually lies on his back while the pain is severe, and has a great indisposition to turn fully on to the affected side. At a later period, when effusion has taken place, the pain usually subsides, and he turns on the side affected to relieve the difficulty of breathing, caused by the pressure of the fluid on the sound lung through the bulging of the mediastinum; but the manner of lying, or _decubitus_, is of little importance, and should be subservient to the feelings of the patient, who is sometimes comfortable only when raised to nearly an erect position.

When the complaint is not subdued at an early period, an effusion of serous fluid, more or less in quantity, takes place. The whole cavity of the side affected has been known to be filled in from twenty-four to forty-eight hours, giving rise to symptoms dependent on the degree to which the effusion has taken place; _this_ is the evil which in injuries penetrating the cavity of the chest is most to be feared. When the external wound has been closed, or is so partially closed as not to allow the escape of the effused fluid, it is commonly the immediate cause of the death of the patient. Its secretion and early evacuation are therefore the most important points to be attended to in wounds of the chest.

The respiratory murmur becomes less distinct as soon as the pain prevents the ordinary distention of the affected side of the chest, and diminishes the quantity of air which usually penetrates the lung in any given time. As soon as a thin layer of fluid commences to be thrown out between the pleuræ, this murmur becomes fainter, and when it is complete, it ceases. If the patient can bear percussion, the side affected yields a dull, dead sound instead of the ordinary clear, sonorous one of health. The position of the patient when erect, by causing the fluid to descend, may allow of the respiratory murmur being heard at the upper part of the chest; and it may be perceived in front, but not behind, when he lies on his back, until the cavity is filled, when the sound altogether ceases. At the spot in the back corresponding to the root of the lung, or at any other point at which a previously formed adhesion may retain the lung against the wall of the chest, some respiratory murmur may yet be distinguished, until this part of the lung shall also have yielded to the general compression, so as to be temporarily impervious, or have become solidified under the continuance and extension of disease. While this is taking place in the affected side, the other lung is called upon to make up the work of aerification of the blood; it labors harder, its functions become more energetic, and that side of the chest is more distended; the respirations become quicker, fuller, and louder, and the vesicular murmur is said to resemble that of a child--in fact, to be _puerile_.

When the lung begins to be compressed by the circumambient fluid and the respiratory murmur ceases, a peculiar modification of the respiration through the large bronchial tubes may be heard, constituting _bronchial_ respiration. It occurs in pneumonia, in pulmonary apoplexy, and in tubercular disease when the lung is solidified. When the voice is heard through the stethoscope in these complaints, the peculiar sound emitted is called _bronchophony_.

In pleuritic effusion, the voice, when carefully examined, sometimes obtains a character not previously noticed, but of comparatively little importance, called _œgophony_, a sound which may be easily confounded with bronchophony, of the latter of which it is a modification more often alluded to than observed. Laennec says: “Simple œgophony consists in a peculiar resonance of the voice, which accompanies or follows the articulation of words. It appears to be sharper than natural, more acute and somewhat silvery, vibrating, as it were, on the surface of the lung more as an echo of the voice than as the voice itself. It rarely enters the tube of the stethoscope, less frequently traverses it completely. It has besides another peculiar character, which is constant, and from which I have taken its name. It is a trembling, bleating, or shaking sound, like that of a goat, the tone of which animal it greatly resembles. When it occurs near a large bronchial tube, as in the root of the lungs, a more or less marked bronchophony is often superadded.” This sound may pervade the whole side; it is usually, however, most distinct near the inferior angle of the scapula, the patient being erect. It only exists where the effused fluid is small in quantity, and is never a dangerous symptom; its return, after it has been present and has disappeared, is a sign that a part of the effused fluid has been removed. It is a sign principally of value in distinguishing between pleuritis and pleuro-pneumonia and pure pneumonia, in which latter disease it is not heard, as in that complaint fluid is not thrown out into the cavity of the pleura.

301. In pneumonia or inflammation of the substance of the lung, as distinct from any implication of the pleura, which, however, most frequently obtains after blows on, and in cases of penetrating wounds of, the chest, the symptoms differ. The ordinary febrile symptoms are similar to those of pleurisy, only more intense; they usually precede for a day or two the local symptoms of difficult respiration, pain, and cough. The dyspnœa varies in different people. In some it is only a slight embarrassment of breathing, admitting of partial removal by accelerating the number of the respirations, which are augmented from twenty to thirty, forty, and upwards, and in children to sixty and seventy, marking a great degree of distress and of extent of inflammation, from which, when they are so frequent, persons rarely recover. The patient can scarcely speak or lie down, and is obliged to be supported in that which he finds to be the least uneasy position. Pain is not always present; it is even said to be more frequently absent when the substance of the lung is affected, and not the pleura. That pain is not a necessary concomitant of pneumonia, is admitted, but that it is usually present, and with great intensity in many cases, cannot be doubted. When present, it is usually an early symptom, deep seated below the sternum, under the breast, extending to the scapula. When in the sides it is more acute and fixed, and is probably conjoined with the pain of pleurisy.

The pulse is quick and sharp, occasionally full and hard, at the commencement of this complaint in young and healthy persons, although it is sometimes small and weak from the beginning, where there is little general power; but this rarely occurs in cases of injury, and is not to be relied upon in opposition to other symptoms.